Info from and between Mental Health Workers, NGO's, Institutes, Service Users and others who are interested in improving Mental Health in Low and Middle Income Countries.

Still waiting for the wedding! 10 good reasons for a marriage between Global Mental Health and the New Technologies

Introduction:
Although the developments in the new technologies (or ICT, information and communication technology) are leapfrogging and even difficult to keep up, the implementations of ICT in the global mental health sector seem still crawling. Grassroots organizations, mental health practitioners and advocates are penetrating the internet and social media with creativity and perseverance, but ‘the establishment’ (global bodies, federations and academic institutes) seem still reluctant to jump. I think they still stick too much to the study/report/journal/email/meeting/congress for their communication, to the book/PDF/lecture/training for the capacity building and to the consultation/diagnose/drug prescription for the treatment of people with mental conditions.

Exact one year ago! I wrote a blog post about this so much desired marriage between Global Mental Health and the New Technologies. This present blog post is an update/revision of that first one, with the same plea for more technology and a couple of new insights and links.

Nine out of ten people with a mental health problem do not receive even basic care in some countries. I’m still very sure that the new technologies, like the internet and mobile devices, can solve part of this treatment gap in Low and Middle Income Countries(LIMICs).

I got all the information from the web and due to the sometimes limited publications (yet) on mental health in this regard, now and then I relied heavily on developments and publications of the more general eHealth and mHealth fields.

1: The new technologies are already there and a worldwide booming business
Although the new technology penetration in developing countries is the lowest worldwide, it’s catching up rapidly with the rest. According to the International Telecommunication Union(ITU) mobile cellular penetration in the developing world reached 70% at the end of 2010 and internet user penetration 21%. Mobile broadband(3G) services are also spreading quickly; by end 2010, 154 economies worldwide had launched 3G networks. This wireless broadband access remains the strongest growth sector in developing countries, with 160% between 2009 and 2010 (ITU). Conversely, the number of dial-up Internet subscriptions has been decreasing rapidly since 2007 and, based on current trends, the ‘death of dial-up’ is expected to become a reality over the next few years.
So, there is a big change that people in developing countries start their activities in the new technology on a mobile device and skip the desktop and wire-line network phase altogether. ‘This ‘mobile miracle’ is putting ICT services within reach of even the most disadvantaged people and communities’, said Dr Hamadoun Touré, ITU Secretary-General. But ‘A new digital divide is unfolding between those with high-speed/capacity/quality access – as is the case in many high-income countries – and those with lower speed/capacity/quality access, as is the case in many low-income countries’ said Mr Brahima Sanou, Director of ITU’s Telecommunication Development Bureau. ‘Policy-makers should act swiftly to facilitate the spread of broadband and ensure that broadband services are faster, more reliable and affordable’ (ITU).
Until fast wireless broadband is available in remote area’s text messages and voice services can offer solutions in ehealth and mhealth. That makes a few free available software platforms like like Frontline SMS (text messages with large groups of people anywhere there is a mobile signal) and MXit (free online mobile instant messenger and social network in Africa), amongst others, very popular at this moment.
People round the world are spending a lot time online and on social networks. In the calculations of Jeff Bullas (and see his beautiful infographics) one in every nine people on Earth is on Facebook, and 33% of them access Facebook through their mobile devices. Over 300.000 users helped translate Facebook into 70 languages. YouTube has 490 million unique users who visit every month and YouTube generates 92 billion page views per month. Flickr hosts over 5 billion images and an average of 190 million Tweets per day occur on Twitter.
The social networks were initiated as a recreational tool, but they are increasingly getting important for business and organizations.
State of art in the global mental health field: The World Federation for Mental Health, has a Twitter account and Facebook page, but ‘forgot?’ to cover there their own World Mental Health Congress 2011 in Cape Town last October. As if someone else is running their social media accounts. The Movement for Global Mental Health has a Facebook Group and a Twitter account as well, but both are quite dormant and not spreading news of the movement itself.
A lot of smaller or local organizations use the social media more enthusiastic. Few examples: the online Mental Health and Psycho-Social Support Network, with in 5 months 6.748 visitors; 53.403 page views from 151 countries and their presence on Twitter, the Lagos State Mental Health Team on Facebook, and the UK Time to Change, let’s end mental health discrimination with 87.850 Facebook Fans, more then 9.000 Twitter followers and dozens of Youtube uploads with together nearly 100.000 views.
Because mental health users, practitioners, caregivers and family members are online and are using there mobile devices abundantly, we must incorporate these technologies in our global mental health organizations and policies. Otherwise we will miss the connection with the daily reality of this new era.

2: Affordable mental health care; saving costs
One of the major problems in the global mental health care in low and middle income countries is the lack of funding (Lancet Series 2007).
In this context it would be a formidable step ahead when for instance evidence based treatments for mental health disorders could be offered on a broad scale and at low costs over the internet. Trying to use the limited time and resources of mental health professionals more efficiently. Ricardo Munoz, of the Internet World Health Research Center wrote an extensive and convincing article on this issue with a ‘proposal to create a central exchange for evidence-based internet interventions’. Quote: ‘The return on investment on Internet interventions that can be used again and again is much higher than from provision of consumable interventions whose therapeutic power is spent after one use. The geographical reach of evidence-based Internet interventions is literally worldwide. This initiative is a worthy and feasible challenge for the 21st century’.
Examples of internet based programs are: the international Stop Smoking Site, the UK Beating the Blues program and the Arabic Internet-based treatment of PTSD.
Another cost-saving example is tele-nursing, where the client can consult a nurse (or other health provider) via the phone for information, advice, a referral or a drug subscription. Mental health examples are the Schizophrenia Research Foundation Telemedicine project and the SATHI Telemedicine based Healthcare support system, both in India for survivors of the 2004 tsunami.
An additional advantage of this kind of distant care is relapse prevention. After finishing a inpatient psychiatric treatment, or emergency psychiatric consult, a lot of the patients drop out of care. Mobile telephone and internet offer easy and user-friendly ways to support these patients on their way back to everyday life.
And last but not least: how much money would we save if we stop travelling around the world for conferences, research, study, consultancies etc. Count in the primary costs for hotels, meeting venues, the drinks and dinners, and the secondary costs in the loss of time. I know it’s marvellous to travel and meet and greet face to face, but think of how many psychiatrists we could recruit and pay for Liberia, Chad and Eritrea (countries with at this moment only one psychiatrist for the whole population) with the money spent on these activities and travelling.
Free web conferencing software can substitute much of these meetings. You have for instance Dimdim.com and oovoo.com, and companies like Google offer ‘reliable, secure web-based office tools for your organization’. Another nice example of reaching lots of people at low costs is a webinar like the one by Dr. Wietse Tol on ‘Mental Health and Psychosocial Support in Humanitarian Settings’, November 2011. Online communities, the social media, online hubs, and thinks like ‘live Twitter chats’ can enhance networking and exchange of opinions and knowledge as well.

3: Reaching people in need in the remote and underserved area’s of the world
Not only are resources for mental health care scarce, they are also inequitably distributed, between countries, regions and within communities (2007 Lancet Series). Low income countries have a median of 0-05 psychiatrists and 0-16 psychiatric nurses per 100,000 population. In high income countries this ratio is 200 times higher. Since most mental health care professionals live in and around the larger cities, rural populations are extra underserved.
If mental health care is offered in a community based model or integrated into primary care the local lay community workers or low educated health workers need extra training, knowledge, supervision and continuous support from elsewhere. The mHealth for Development report of the UN Foundation and the Vodafone Foundation, the eHealth Tools and Services report of the WHO, the Question 14-2/2 study of the ITU and the special mHealth dossier of the Dutch Royal Tropical Institute, offer all a broad array of applications for this remote control support in developing countries. For instance shared electronic records, computer assisted prescription of medicines and step by step diagnosis decision trees, wiki’s, video conferencing, tele-pharmacy, second opinion and distant consultations. A nice example is a project in the Caribbean with the portable digital assistance(PDA), for nurses, to empower diagnosis and decision making. Another example of is the mobile phone case management solution for Community Health Workers CommCare. It’s piloted in ten countries by 19 public health organizations for HIV+ and chronic care patients, general health promotion, safe pregnancies and vulnerable children.
I stumbled upon only a few examples in the mental health field, like the the GMHAT, Global Mental Health Assessment Tool, a computer assisted clinical interview to be used in routine clinical practice to detect and manage mental disorders. And the Better Access to Mental Health Care Program in Australia. They build an internet tool box for rural GPs to access mental health services information, which was quite successful.
And in order to reach patients in remote area’s, or immobile patients, mental health practitioners can use mobile or internet care-at-home programs like video monitoring, online encrypted chats/mail via free providers like Skype and Hushmail and the tele-nursing. An nice example of an application is a Doctor in your Pocket, a phone based primary care model, used successfully in a few developing countries. Another example is the use of SMS services to clients for drug adherence and relapse prevention, like the On Cue project in South Africa. Health workers were sending SMS out within a chosen time frame, to remind patients with tuberculoses for drug regime compliance. The costs for this SMS service was $16 patient/year and the they had a 99,3% compliance rate. Another medication adherence solution is SIMpill, it can monitor the intake of medication at real time and remind patients and carers as necessary by sending a text message to the patient and/or carers mobile phone if the patient does not take their medication as prescribed. A last one is the MoTech, Mobile Technology for Community Healt, in Ghana. This ‘mobile midwife’ service enables pregnant women and their families to receive SMS or voice messages that provide time-specific information about their pregnancy each week in their own language. This information is a mixture of alerts and reminders for care seeking (e.g., reminders to go for specific treatments, such as prenatal care or a tetanus vaccination) and advice to help deal with challenges during pregnancy.

4: Anticipating on the globalization and movement of people
Immigration is a key part of globalization. According to International Organization for Migration(IOM) there are now more then 200 million immigrants worldwide. The ITU reports that in 2007 there were 36 million expatriates worldwide and more then 898 million people crossed national boundaries, which number is expected to increase to 1.56 billion in 2020. And according to the World Development Report 2011, there were 42.3 million people displaced globally in 2009. Of these 15.2 million were refugees outside their country.
In a comment on the 2007 Lancet series Dinesh Bhugra and Iraklis Minas state that although globalization can promise universal and economic benefits, for a lot of the people on the move it can lead to increased marginalization, unemployment, increased poverty, facing violence and other adversities. The encounter between people and other cultures can result in acculturation problems, leading to extra distress and dysfunction in some individuals and tension between cultural groups.
Emergencies and violence produce large flows of asylum seekers and refugees, often in low and middle income neighboring countries which have little capacity to receive them and take care of them, even more overstretching local limited resources.
With many countries having multiple local and regional languages, communicating with care givers in the language you know can be crucial for help and accurate advice. Personal health info and records can be accessed online (see point 6) and shared with a professional elsewhere. Free encrypted mail and chat sites (see point 3) make communication with far away mental health professionals possible and with 100% privacy (if used properly), and some of the online interventions mentioned above (point 2) can be accessed worldwide. So, with the new technologies people can ‘take their mental health care with them’, wherever they go.

5: Fighting stigma and raise awareness about mental health conditions
A lot of people with mental health problems are subject to stigma, exclusion and discrimination. This stigma and lack of knowledge about mental disorders can result in a strong avoidance in seeking treatment, and efforts of family members to ignore or conceal the mental health problems of their family member. Often patients are still locked up or chained out of sight and the conditions in many mental hospitals are appalling and treatments abusive. According to the Lancet article ‘Human rights violations of people with mental and psychosocial disabilities: an unresolved global crisis’ ‘people with mental and psychosocial disabilities are incorrectly perceived to be violent, dangerous, or unpredictable. Such negative attitudes are held not only by the general public, but also by health professionals and policy makers’.
A strong advocacy is required to shift these attitudes and behavior, at all levels: the people with mental health problems, the family, the community, health workers, civil society, government, bilateral and multilateral agencies, donors, etc.
A good start is the UN Convention on the Rights of Persons with Disabilities(CRPD), which since its entry into force in 2008 provides the first comprehensive and legally binding international framework for promoting the rights of people with mental and psychosocial disabilities. A lot of countries and organizations are, or have been, ratifying this convention.
Another initiative is the launch of the ‘the great push for mental health’ of the WFMH. They have a vision ‘of a world in which mental health is a priority for all people’. Their major themes are: unity, visibility, rights and recovery. They stress, amongst other things, fighting the stigma by means of public events like grass-roots campaigns, national parades on the World Mental Health Day 10 October, petitions, conferences and the use of the social media.
Good examples of mental health stigma fighters with a extensive social media appearance are the aforementioned Time to Change in the UK, Mind Freedom in the US and Sane in Australia. The photographer Robin Hammond is documenting ‘the mental health impacts of crises in Africa’ with photos and a video on Youtube and is trying to get more funding for his ‘Condemned Project’ via internet. A last example here is Jagannath Lamichhane, journalist in Nepal, who writes about the stigma and mental health conditions in his country regularly (few links to his articles) and has over 3000 followers/friends on Facebook and just started on Twitter.
And don’t forget raising awareness via the mobile phones. In the UN Foundation and Vodafone Foundation report is concluded that ‘formal studies and anecdotal evidence demonstrated that SMS alerts have a measurable impact on and a greater ability to influence behaviour than radio and television campaigns’. Example of a successful SMS awareness campaign is the HIV/AIDS Text To Change, a SMS-based quiz to 15,000 mobile phone subscribers during 3 months in Uganda. The quiz produced 40% more patients who came in for testing, from 1,000 to 1,400, during a 6-week period.

6: Empowerment and independence of users and caregivers
A vast amount of people with mental health problems are not meeting any mental health professional at all. Reasons can be the huge lack of services, or lack of understanding about the benefits of services, lack of money, stigma or other reasons. Others are meeting (mental) health professionals, but face insufficient or bad treatment or violations of basic human rights (see point 5). People from both groups, including their caretakers, will benefit from more information about conditions and treatment, more ownership, more possible choices, decisions and support.
Nowadays there is 7 x 24 access to online information, suicide-prevention and emergency sites/telephone numbers like Befrienders Worldwide, Suicide.org and the Hot Peaches Pages (for domestic violence services).
There are apps on mobile devices like the T2 MoodTracker application of the US army, Mobile Therapy, a cell phone application for ’emotional self-awareness’ and if you stroll for instance the Apple iPhone app or other brand app stores, you can find apps to help with relaxation, anxiety, anger management, eating disorders, obsessive compulsive disorder, and substance use recovery. And there are internet services like Personal Health Records(PHR’s) like Microsoft HealthVault.
With these applications people can manage a part of their mental health care themselves, wherever they are or at what time of the day.
All these technologies can play an important part in the ‘self care’ level of the WHO Pyramid: ‘the optimal mix of mental health services’. In this pyramid self care refers to care without individual professional input and is the most frequent needed and cheapest care (the bottom of the pyramid). And in all other levels self care is essential and occurs simultaneously with the professional services.
According to Amita Dhanda and Thelma Narayan in their Lancet series comment 2007 user and self-help groups can play a important rule in the everything that is ‘wider then the medical establishment’, like peer- and family support, rehabilitation, training. Addressing issues like livelihood, life skills, education, occupation, parenting skills, local healing traditions etc. Examples of user and self-help groups are the Alcohol Anonymous, the World Network of Users and Survivors of Psychiatry with national and regional networks as well, Intervoice for people who hear voices, and as an excellent example the South African Depression and Anxiety Group, with a network of over 180 Support Groups, emergency hotlines and more then 450 000 website hits per month!
A lot of these user or activism groups have a high internet and social media presence and use the internet for contact, actions and news.

9: Bottom up and demand driven programs
Before the so called web2.0 era, the information stream was mostly one way, top down, from institutes and plan makers in developed countries, to their recipients in developing countries. In recent reports of the WHO and in the the recent Lancet series on Global Mental Health you can see more grass roots and non-academic contributors, like Charlene Sunkel of the Gauteng Mental Health Society, South Africa, and more and more recommendations to consult users and their movements. For example in the WHO report Mental Health and Development: ‘Improve development outcomes by increasing outreach to and consultation with people with mental health conditions, supporting the establishment and development of service user groups, and funding these groups to participate in public affairs and advocacy work’.
Giving service users and caregivers more voice and influence in policies and plans can prevent project failure and creates at the same time rehabilitation opportunities and skill and knowledge development in the people involved. Or formulated in the Cape Town declaration of 16 October 2011 of the Pan African Network of People with Psychosocial Disabilities(PANUSP): ‘We are people first! We have potentials, abilities, talents and each of us can make a great contribution to the world. We in the past, presently and in the future, have, do and will continue to make great contributions if barriers are removed’.
In the field of the global mental health there are a couple of communities online like the Mental Health Community, the Society for Emotional Well-being Worldwide and others which are already mentioned. And there are numerous blogs, pages and accounts. A lot of them are individual initiatives and opinions, others are service user groups like for instance the Users and Survivors of Psychiatry Kenya, or activism sites like the Anjali Mental Health Rights Organization in Calcutta, India, both with Facebook pages as well.
Just a person or group somewhere in the world, circulating information for whoever wants to read it……. So, global mental health organizations, institutes and policymakers, if you really want to get in touch with the grass roots practitioners and the users ‘in the field’, just jump in the web2.0, join, ask, discuss; listen and contribute.

10: Useful data for research, planning and evaluation: standardizing and easy access
In calls for solving the global mental health treatment gap pleas for more research, evidence based treatments, randomised controlled trials, and stimulation of collaboration between researchers and practitioners are often heard (Lancet series 2011). And the Grand Challenges Canada for Global Mental Health offered funding for a new generation of research of ‘innovative solutions for improving treatments and expanding access to mental health care in low- and middle-income countries’.
But when for instance the World Psychiatric Organization reviewed systematically the development of community mental health care in Africa, they find a diversity of data and methods, which gave some insight in the matter, but not reliable figures or clear comparable outcomes.
Patricia Mechael and her team of the Center for Global Health and Economic Development Earth Institute concluded in their Barriers and Gaps Affecting mHealth in Low and Middle Income Countries report, that ‘a proactive cycle of strategy, implementation and evaluation to in turn inform strategy at the global, national, regional, district, and community levels will generate the platform needed for implementation of more and better mHealth systems that generate health benefits for citizens and health workers in Low and Middle Income Countries’. After reviewing nearly 2,994 peer-reviewed publications and secondary sources, the consensus was that there are a lot of very small scale studies and ‘that you can make almost anything good in pilot. The challenge is how to conduct research at a significant enough scale to figure out what works and what doesn’t work’.
An answer on this challenge are the new technologies. First hand data about patients, tools, treatments and costs, obtained on the spot, can be transported quick and cheap via the internet to everywhere. With mobile devices and standardized apps/programs, a lot of paper work can be skipped and information can be processed immediately at the other side of the world. An example of such application is theTB prevention/vaccine program from Cmed and Aeras. They captured electronically data from three clinical sites in South Africa, while managing and analyzing the data from its headquarters in Rockville, Maryland USA in near real time. Another example of software is EpiSurveyor of DataDyne. This software allows anyone to set up a worldwide, mobile-phone-based data collection system in minutes, for free. The Vodafone Foundation and the UN Foundation used this software app for example to equip health workers in more than 20 sub-Saharan countries.

Conclusions and recommendations
A main challenge in this marriage between the new technologies and global mental health is the need of a broad multi-sector collaboration. As A. Iluyemi and J.S. Briggs of the University of Porthsmouth analyzed : ‘Project failure in ehealth and mhealth has been partly due to a lack of coherence between social and technological aspects of the system design and practice. To much focus on the ‘soft’ side of information systems to the detriment of the ‘hard’ ones’. Or, from the mHealt for Development report, ‘to accelerate this momentum and fully unleash the potential of mHealth applications, dynamic multi-sector collaboration between groups as diverse as governments, multilateral organizations, and the private sector is needed’. According to the ITU, in their Tele-Health in India report, special additional attention needs the billing systems for services. They can become multi-tier and very complicated as the ehealth system matures. It will save time and costs if from the start proven money transaction techniques, like for instance M-PESA, are incorporated in the plans.
Since the awareness and knowledge of the medical staff in developing countries about ehealth and computers is low, the International Telecommunication Union recommends more training and capacity building in this field. They developed a special training course for participants from developing countries which was successfully launched in 2008. For the ITU, in their report on Tele-Health in India ‘video conferencing, including, if necessary, a real time human translator to counter linguistic barriers, seems to be the pivotal application in education and acceptance of eHealth by doctors and patients alike’. The WHO Global Observatory for eHealth advocates strongly for inclusion of eHealth courses within university curricula as well. And Patricia Mechael and colleagues argue that: ‘Additional efforts in educating health professionals about the potential role of ICT in healthcare delivery will be critical for mass adoption. These must be focused on the benefits to the professionals themselves.’
According to the UN Foundation and Vodafone Foundation and A. Iluyemi and J.S. Briggs in their article ‘Technology matters’, during the design and implementation of the new technologies the end user must be kept in mind. Using the simplest available technology and adapting the plans to the ICT trends in developing countries like the use of mobile/wireless ICT devices in stead of the more traditional wire-line networks and desktop computers. Low cost laptops like the One Laptop Per Child (OLCP) XOI device, which can withstand the harshest environmental conditions, have a long battery life and a wireless connectivity, are very useful in this context.
There are a few important hazards with the use of internet and mobile services. For instance: ‘All info lays on the street’ and commercial companies try to profit from the information and data available. Although most of the security problems encountered on the Internet are due to human mistakes, I think these privacy concerns must be addressed in all parts of the program designs and be a part in the education and supervision of health workers as well. There are solutions like encrypted data transport and codes/passwords, but this means extra technical knowledge and a consequent use in practice by all people involved.
Extra caution is also needed in the use of the information derived from the web like articles/blogs, research data/figures and advices and conclusions. As the ‘Frontier Psychiatrist’ argues: ‘There is no guarantee of authoritative control over the content and content can be false, changed or malicious due to commercial influence. Overall it would be wise to double check any information gleaned from a blog, wiki or tweet, since the content of any information on internet is no more reliable then its administrator’.
Another concern comes from the International Development Research Centre(IDRC) in Canada. They think that the developing countries have both the most to gain and the most to lose from e-applications like eHealth. Because of the digital divide, there is a risk that the least developed countries will be excluded from the potential gains. And because a lot of funding, time and effort is needed to raise their health and eHealth infrastructure to the required levels, their debts can be increased or potentially diverting funding away from already stressed traditional health care delivery and support. So we must try to get the poorest countries on board. The 2005 WHO WHA58.28 e-Health resolution may be a turning point; drawing the attention of domestic governments of member countries to the potential of, and the need for, e-health in each of their countries. Other initiatives like the healthcare divisions of a few big telecom companies like Telefónica, Orange, amongst others, and global alliances like the ITU, the Global Observatory for eHealth, mHealth Alliance, the Database of European eHealth Priorities and Strategies are also promising, although no one is yet specialized in global mental health. And this makes a small bridge to my last worry: although the eHealth and eMental-Health fields are at least overlapping, eMental-Health has own features and challenges. Although a few colleagues are real ambassadors of e-Mental-Health in the poorest and remote area’s of the world, I think it is yet a bit too quiet.

I hope this paper is convincing enough. That, despite the hazards and obstacles, the new technologies are part of the solution of the mental health treatment gap and can’t be ignored or left to the few ICT freaks in the field.

In the context of millions of people who are struggling with untreated treatable mental health conditions, neglecting the eMental-Health applications in policies and plans is, I think, even a immoral deed.

Comments

I would be happy if you keep me ihformed about future developments. With only very few support I try to develope a program on Rural High Mountain (difficult access) Psychiatry in Venezuela (Trujilllo State) as compared to psychiatric consultations of rural patients consulting at my large urban Hospital Vargas de Caracas. Regular follow up as well as esential medicines being the main problems
Many thanks in advance.
HS

Dear Herbert. Your rural high mountain service sounds really challenging indeed. For information about further developments, you can subscribe to new posts on this in2mnetalhealth website (‘notify me of new pots via mail’ TAB).
Other websites like mobileactive.com, mhealthalliance.org and k4health.org, amongst others, spread very valuable info about ehealth and mhealth on weekly base. For exchange of experiences, tips and field reports, I would advice engaging the HIFA2015.org email forum. But probably you know already these sources. Good luck! Roos Korste

I completely agree with your point about the necessary marriage. I’m actually working on building more social networking into the site for an organization the Society for Emotional Wellbeing Worldwide (www.seww.org). I am very excited to find your blog post on this topic!